A behavioral emergency, also called a behavioral crisis or psychiatric emergency, occurs when someone’s behavior is so out of control that the person becomes a danger to everyone. The situation is so extreme that the person must be treated promptly to avoid injury to themselves or others. Time is of the essence in a behavioral emergency, so it is important to recognize the symptoms of this type of emergency and to realize the degree to which the situation can escalate if immediate steps are not taken to diffuse the situation.
The symptoms of a behavioral emergency include extreme agitation, threatening to harm yourself or others, yelling or screaming, lashing out, irrational thoughts, throwing objects and other volatile behavior. The person will seem angry, irrational, out of control and unpredictable. The unpredictable nature of this type of emergency can lead to injuries to bystanders if the sufferer displays violent behavior during the episode.
Reasons for Behavioral Emergencies
Behavioral emergencies can arise due to mental illness, substance abuse or another medical condition. Medical conditions that can cause the type of mental changes required for a behavioral emergency include low blood sugar related to diabetes or hypoglycemia, hypoxia, a traumatic brain injury or reduced blood flow to the brain and central nervous system infections such as meningitis.
In general, all possible physical medical conditions or substance abuse explanations should be ruled out before blaming a behavioral emergency on a mental illness, especially in someone who does not have a previous diagnosis or history of other symptoms. Mental changes that have a sudden onset or that are accompanied by incontinence, memory loss, excessive salivation or visual (in the absence of auditory) hallucinations are more likely to be caused by a physical condition rather than a mental illness.
Anxiety’s Role in Behavioral Emergencies
Anxiety is a common mental condition that can also lead to a behavioral emergency. Approximately 10 percent of all adults suffer from anxiety, making it the most prevalent psychiatric illness. Symptoms of anxiety include extreme uneasiness and worry, agitation and restlessness. Although the symptoms of anxiety are relatively easy to recognize, it is often misdiagnosed.
People who suffer from anxiety can have panic attacks, which are intense episodes of fear and tension that can overwhelm the sufferer and quickly lead to a behavioral emergency. The sufferer may lose the ability to concentrate, focus and rationalize feeling and body’s responses to those feelings.
Symptoms of a panic attack include:
- Racing or pounding heartbeat
- Heart palpations or an irregular heartbeat
- Dizziness
- Tingling or numbness of the fingers and mouth
- Uncontrollable shaking as though the person is very cold and teeth chattering
- Shortness of breath
If a sufferer learns to recognize the symptoms of an impending panic attack before the symptoms become too extreme, that person may avoid a behavioral emergency.
Anxiety is not the only mental medical condition that can result in a behavioral emergency. Depression, bipolar disorder and schizophrenia can all cause symptoms that can overwhelm the sufferer enough to lead them into a behavioral emergency, especially if these conditions are undiagnosed or untreated or if the sufferer abruptly stops taking his or her medication.
The Role of Violence in Behavioral Emergencies
The biggest danger of a behavioral emergency is that it may result in harm to the sufferer or bystanders. Up to 70 percent of those suffering from a behavioral emergency attempt to assault others or display behavior that can harm others, so this is a very real concern. The first priority should be the safety of all the people involved the situation, followed by attempts to diffuse the situation and the treatment of the sufferer to avoid future emergencies.
There are many reasons why someone may become violent during a behavioral emergency, including a real or perceived threat, fear and panic, head trauma or the influence of a substance. Warning signs of impending violence include pacing, yelling, making threats and clenched teeth or fists. These warning signs should be taken seriously and not overlooked, as ignoring them could have disastrous and even fatal results.
Ways that a sufferer may become violent include direct physical violence, the threat of physical violence with a weapon and throwing objects in the direction of others. Although the desire may be to help the sufferer, personal safety should be most important.
Techniques to Handle a Behavioral Emergency
If you are confronted with a behavioral emergency it is important to stay calm. Your fear and uneasiness will only escalate the situation and possibly make the sufferer’s panic and agitation worse. It is important to speak directly to the sufferer, establish and maintain eye contact and speak reassuringly. Do not make any sudden movements that can be misinterpreted by the sufferer and keep some distance between the two of you. Remain with the sufferer at all times.
When speaking to the sufferer, it is important to remain honest and truthfully answer any questions. If that person is having hallucinations, do not pretend that you see the hallucinations. This is not the time to tell the sufferer to make any decisions. It is important to remain supportive and not get accusatory or make the sufferer feel belittled. Asking the sufferer to perform simple tasks can help keep them present instead of losing them in a delusion or hallucination.
Behavioral emergencies can be stressful for all involved. These situations are not uncommon, so it is important to know how to deal with them. Keeping calm and keeping the sufferer as calm as possible will go a long way in making the situation as bearable and safe as possible until it is diffused completely. The sufferer will likely require intensive treatment after the episode to either recuperate from an underlying physical medical condition or to diagnosis and treat a mental medical condition or substance abuse problem. Treatment is important to reduce the chance of a second episode.
For more on the topic of Behavioral Emergencies, we’ve included the following expert consensus documents as reference materials:
View Resources
- Guidelines.gov – Rapid response team.
- NIH.gov – Psychiatric emergencies.
- NIH.gov – An EMS approach to psychiatric emergencies.
- NIH.gov – What do consumers say they want and need during a psychiatric emergency?
- CDC.gov – Coping With a Disaster or Traumatic Event
Chapter 12: Behavioral Emergencies
National EMS Education Standard Competencies (1 of 3) Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.
National EMS Education Standard Competencies (2 of 3) Psychiatric Recognition of • Behaviors that pose a risk to the emergency medical responder (EMR), patient, or others
National EMS Education Standard Competencies (3 of 3) Special Patient Populations Recognizes and manages life threats based on simple assessment findings for a patient with special needs while awaiting additional emergency response. Patients With Special Challenges • Recognizing and reporting abuse and neglect
Introduction • EMRs need to give psychological support as well as emergency medical care. • Factors contributing to behavioral changes – Medical conditions – Physical trauma – Psychiatric illnesses – Mind-altering substances – Situational stresses
Patient Assessment in Behavioral Emergencies (1 of 3) © Jones & Bartlett Learning. Courtesy of MIEMSS.
Patient Assessment in Behavioral Emergencies (2 of 3) • Complete a scene size-up, being especially careful to make sure that the scene is safe. • If the patient is oriented and responsive, complete the primary assessment. – Observe the patient’s responsiveness, airway, and breathing, and measure the pulse. • The history should follow the SAMPLE format.
Patient Assessment in Behavioral Emergencies (3 of 3) • The secondary assessment should rule out any obvious injuries and focus on signs of medical illnesses. – Take a set of vital signs. • Reassess stable patients every 15 minutes and unstable patients every 5 minutes. • If you cannot complete the assessment, document the reason for not completing it.
Behavioral Crises (1 of 4) • Behavioral emergencies are situations in which persons exhibit abnormal, unacceptable behavior that cannot be tolerated by the patients themselves or by family, friends, or the community. • Medical conditions – Uncontrolled diabetes – Respiratory conditions – Strokes
Behavioral Crises (2 of 4) • Medical conditions (cont’d) – Head injuries – High fevers – Infections – Excessively low body temperature • Physical trauma – Head injuries – Injuries that result in shock and an inadequate blood supply to the brain
Behavioral Crises (3 of 4) • Psychiatric illnesses – Depression – Panic – Psychotic behavior • Mind-altering substances – Alcohol – A wide variety of chemical substances
Behavioral Crises (4 of 4) • Situational stresses – Death of a loved one – Serious injury to a loved one
What Is a Situational Crisis? • State of emotional upset or turmoil • Caused by a sudden and disruptive event • Most situational crises – Are sudden and unexpected – Cannot be handled by the person’s usual coping mechanisms – Last only a short time – Can cause socially unacceptable, selfdestructive, or dangerous behavior
Phases of a Situational Crisis • There are four emotional phases to each situational crisis. • People may not experience every phase, but they will experience one or more.
High Anxiety or Emotional Shock (1 of 2) • High anxiety is characterized by – Flushed (red) face – Rapid breathing – Rapid speech – Increased activity – Loud or screaming voice – General agitation
High Anxiety or Emotional Shock (2 of 2) • Emotional shock is often the result of a sudden illness, accident, or sudden death of a loved one. • Emotional shock is characterized by – Cool, clammy skin – A rapid, weak pulse – Vomiting and nausea – General inactivity and weakness
Denial • Refusal to accept the fact that an event has occurred • Your response should be as follows: – Allow the patient to express denial. – Do not argue with the patient. – Try to understand the emotional and psychological trauma that the patient is experiencing.
Anger • Normal human response to emotional overload or frustration • May follow denial or may replace denial • People may vent angry feelings at you. – Do not take the person’s anger personally. • Frustration and a sense of helplessness can often build to anger. – Always be professional and remain calm.
Remorse or Grief • Acceptance of the situation may lead to remorse or grief. • People may feel guilty or apologetic about their behavior. © Jones & Bartlett Learning. Courtesy of MIEMSS.
Crisis Management • Role of the EMR – Follow the steps of the patient assessment sequence. – After the primary assessment, you may need to obtain the patient’s medical history or perform a physical examination. – Your most important assessment skill may be your ability to communicate with the patient.
Communicating With the Patient (1 of 6) • Talk with the person. – Introduce yourself. – Ask the patient his or her name. © Jones & Bartlett Learning. – Ask what you can do to help. • Be honest, warm, caring, and empathetic. • Position yourself at the patient’s eye level. © Jones & Bartlett Learning.
Communicating With the Patient (2 of 6) • Establish eye contact with the patient. • Use a calm, steady voice and provide honest reassurance. • Try not to let negative personal feelings interfere with your attempt to provide assistance. • Simple acts of kindness can provide comfort and reassurance.
Communicating With the Patient (3 of 6) • Restatement – Rephrasing a person’s own words and thoughts and repeating them back – Be honest and give the patient hope, but do not give false hope. • Redirection – Helps focus a patient’s attention on the immediate situation or crisis
Communicating With the Patient (4 of 6) • Redirection (cont’d) – Use redirection to alleviate a patient’s expressed concerns. – Move the patient to a quieter and more private location. • Empathy – Imagining yourself in another person’s situation and sharing his or her feelings or ideas
Communicating With the Patient (5 of 6) • Empathy (cont’d) – Empathy is one of the most helpful concepts you can use. – Use a calm and caring approach. • Communication skills – Identify yourself and let the patient know you are there to help. – Inform the patient of what you are doing.
Communicating With the Patient (6 of 6) • Communication skills (cont’d) – Ask questions in a calm, reassuring voice. – Allow the patient to tell you what happened—do not be judgmental. – Show you are listening by using restatement and redirection. – Acknowledge the patient’s feelings. – Assess the patient’s mental status.
Crowd Control • Performing crowd control may help reduce a patient’s anxiety when there are too many people around. • During your size-up of the scene, determine whethere is a crowd that might become hostile. – It is better to ask for help early than to wait.
Domestic Violence (1 of 6) • Common occurrence in today’s society • It takes several different forms: – Elder abuse – Child abuse – Spouse and domestic partner abuse • When responding to a domestic call – Maintain safety for all rescuers as well as for the patient.
Domestic Violence (2 of 6) • When responding to a domestic call (cont’d) – Conduct an effective assessment and treatment. – Understand the requirements for reporting abuse in your state. • Physical signs and symptoms – Broken bones – Cuts
Domestic Violence (3 of 6) • Physical signs and symptoms (cont’d) – Head injuries – Bruises – Burns – Scars from old injuries – Injuries in various stages of healing – Internal injuries
Domestic Violence (4 of 6) • Emotional symptoms – Depression – Suicide attempts – Abuse of alcohol or drugs – Feelings of anxiety, distress, and hopelessness • Abusers may be paranoid, overly sensitive, obsessive, or threatening.
Domestic Violence (5 of 6) • If you suspect abuse, your responsibility is to maintain safety for yourself and for the patient. – Try to separate the patient from the abuser. – Try to keep from judging the patient. – The presence of law enforcement personnel may be helpful. – Learn the requirements for reporting abuse in your state.
Domestic Violence (6 of 6) • Cycles of abuse – Tension phase: The abuser becomes angry and often blames the victim. – Explosive phase: The abuser becomes enraged and loses control as well as the ability to think clearly. – Make-up phase: The abuser makes promises, which are seldom kept.
Violent Patients (1 of 3) • Immediately attempt to establish verbal and eye contact with the patient. • Check with family and friends about the patient’s past history of violence. • Signs of potential violence © Jones & Bartlett Learning. – History of violence – Yelling or verbal threatening
Violent Patients (2 of 3) • Signs of potential violence (cont’d) – Loud, obscene, or bizarre speech – Pacing, inability to sit still, and protection of personal space – Abuse of drugs or alcohol • Never force a potentially violent patient into a corner, and do not allow yourself to be cut off from a route of retreat.
Violent Patients (3 of 3) • Have only one person talk with the patient. – The communicator should be the rescuer with whom the patient seems to have the best initial rapport. • Anticipate the need to summon law enforcement personnel if all else fails.
Violence Against EMRs (1 of 3) • Factors that increase the risk of violence in the workplace – Working alone or in small numbers – Working late at night or early in the morning – Working in high-crime areas – Working in community settings
Violence Against EMRs (2 of 3) • Be alert when you respond to a call that has an increased chance for violence, including the following situations: – Crime scenes – Incidents involving gangs – Large gatherings of hostile or potentially hostile people – Domestic disputes
Violence Against EMRs (3 of 3) • Ways to minimize the risk of injury – Take steps to keep yourself and other rescuers safe at these scenes. – Always keep an escape route open between you and the patient. • Prevention – Best way to avoid violence – Make sure you have an escape route in mind.
The Armed Patient • It is not your role to handle an armed patient unless you are a law enforcement officer. • Be alert and summon assistance. • Stay in your vehicle if you must wait for a law enforcement officer. • If you are confronted by an armed person, immediately attempt to withdraw.
Medical and Legal Considerations (1 of 3) • If an emotionally disturbed patient agrees to be treated, few legal issues should arise. • If a patient who appears to be disturbed refuses treatment, you may have to provide care against the patient’s will. – You must have a reasonable belief that the patient would harm self or others.
Medical and Legal Considerations (2 of 3) • If you are required to restrain a patient, consider the following factors: – The patient’s size and apparent strength – The patient’s gender – The type of abnormal behavior – The patient’s mental state – The method of restraint
Medical and Legal Considerations (3 of 3) • You may use reasonable force to defend yourself against an attack. • Seek assistance from law enforcement officials or from your medical director. • Document the conditions present. • Whenever possible, a caregiver of the same sex should take primary responsibility for the care of the patient.
Attempted Suicide (1 of 2) • Many patients who fail at their first attempt will try to commit suicide again. • The underlying psychiatric disease is usually treatable. • Management – Protect yourself and the patient from further harm. – Obtain a complete history of the incident. – Determine whether the patient still has a weapon or drugs on him or her.
Attempted Suicide (2 of 2) • Management (cont’d) – Support the patient’s ABCs. – Dress any open wounds. – Treat the patient for spinal injuries. – Do not judge the patient. – Treat the patient for the injuries or conditions you discover. – Provide emotional support.
Posttraumatic Stress Disorder (1 of 2) • A mental health or behavioral condition triggered by experiencing or witnessing a terrifying event. • Symptoms include – Intrusive memories of the traumatic event – Avoidance of places, activities, or people that remind them of the traumatic event – Negative feelings – Emotional reactions
Posttraumatic Stress Disorder (2 of 2) • As an EMR, your job is to – Protect the patient from harm. – Speak with the patient in a positive and supportive way. – Arrange for the patient to be transported to an appropriate medical facility.
Sexual Assault (1 of 2) • The psychological aspects of treatment are important. • You may have to delay all but the most essential treatment until a responder of the same sex as the patient arrives. • Your first priority is the medical well-being of the patient. – Treat any injuries the person may have.
Sexual Assault (2 of 2) • Sexual assault is a crime. – Do not remove clothing except to give medical care. – Try to convince the patient not to bathe or use the toilet. – Keep the scene and any evidence as undisturbed and intact as possible. – Avoid aggressively questioning the patient. – Treat the patient with empathy.
Death and Dying (1 of 2) • You will encounter death and dying from natural, accidental, and intentional causes. • Do whatever you can to meet the patient’s medical needs. • Most people are afraid of dying. – Work through your personal feelings about death.
Death and Dying (2 of 2) • Consider the psychological needs of the patient and his or her family. © Jones & Bartlett Learning. – Do not be afraid to touch. – Make positive statements, but do not give false hope. – Provide comfort in any way you can.
Critical Incident Stress Debriefing (1 of 2) • EMRs may need counseling to deal with the stresses of providing emergency care. • Signs and symptoms of extreme stress – Depression – Inability to sleep – Weight changes – Increased alcohol consumption or drug abuse
Critical Incident Stress Debriefing (2 of 2) • Signs and symptoms of extreme stress (cont’d) – Inability to get along with family and coworkers – Lack or interest in food or sex • Critical Incident Stress Debriefing (CISD) brings rescuers and a trained person together to talk about the rescuer’s feelings.
Summary (1 of 4) • Only a small percentage of the patients you treat will be severely mentally disturbed, but almost every patient you care for will be experiencing some degree of mental and emotional crisis.
Summary (2 of 4) • Behavioral emergencies are situations in which persons exhibit abnormal, unacceptable behavior that cannot be tolerated by the patients themselves or by family, friends, or the community.
Summary (3 of 4) • Five major factors cause behavioral crises: medical conditions, physical trauma conditions, psychiatric illnesses, mindaltering substances, and situational stresses. • The four emotional phases to each crisis are high anxiety or emotional shock, denial, anger, and remorse or grief.
Summary (4 of 4) • Your role as an EMR consists of assessing the patient and providing physical and emotional care. Your most important assessment skill may be your ability to communicate with the patient. • If a patient who appears to be disturbed refuses to accept treatment, you may have to provide care against the patient’s will.
Review 1. Behavioral emergencies are situations in which a person exhibits A. abnormal behavior that is deemed unacceptable by others. B. mild to moderate depression over a long period of time. C. anger that is justified by the situation. D. strange behavior, but is otherwise mentally stable.
Review Answer: A. abnormal behavior that is deemed unacceptable by others.
Review 2. Which of the following is NOT considered an emotional phase in a situational crisis? A. Anger B. Denial C. Grief D. Violence
Review Answer: D. Violence
Review 3. When treating a patient with PSTD, one of your responsibilities is to A. protect the patient from harm. B. speak with the patient in an authoritative, forceful way. C. convince the patient to take care of the problem himself or herself. D. contact law enforcement immediately.
Review Answer: A. protect the patient from harm.